methods of controlling venereal disease, as small-pox, typhus, and to a
large extent typhoid, have already been controlled. The Commission was
well composed, not merely of officials and doctors, but of experienced
men and women in various fields, and the final Report is signed by all
the members, any difference of opinion being confined to minor points
(which it is unnecessary to touch on here) and to two members only. The
recommendations are conceived in the most practical and broad-minded
spirit. They are neither faddy nor goody-goody. Some indeed may wish that
they had gone further. The Commission leave over for later consideration
the question of notifying venereal disease as other infectious diseases
are notified, and there is no recommendation for the provision of
preventive methods against infection for use before intercourse, such as
are officially favoured in Germany. But at both these points the
Commissioners have been wise, for they are points to which sections of
public opinion are still strongly hostile.[4] As they stand, the
recommendations should carry conviction to all serious and reasonable
persons. Already, indeed, the Government, without opposition, has
expressed its willingness to undertake the financial burden which the
Commission would impose on it.
The main Recommendations made by the Commission, if we put aside the
suggestions for obtaining a more exact statistical knowledge, may be
placed under the heads of Treatment and Prevention. As regards the
first, it is insisted that measures should be taken to render the best
modern treatment, which should be free to all, readily available for
the whole community, in such a way that those affected will have no
hesitation in taking advantage of the facilities thus offered. The
means of treatment should be organised by County Councils and Boroughs,
under the Local Government Board, which should have power to make
independent arrangements when the local authorities fail in their
duties. Institutional treatment should be provided at all general
hospitals, special arrangements made for the treatment of out-patients
in the evenings, and no objection offered to patients seeking treatment
outside their own neighbourhoods. The expenditure should be assisted by
grants from Imperial Funds to the extent of 75 per cent. It may be
added that, however heavy such expenditure may be, an economy can
scarcely fail to be effected. The financial cost of venereal disease
to-day is so vast as to be beyond calculation. It enters into every
field of life. It is enough merely to consider the significant little
fact that the cost of educating a deaf child is ten times as great as
that of educating an ordinary child.
Under the head of Prevention we may place such a suggestion as that the
existence of infective venereal disease should constitute legal
incapacity for marriage, even when unknown, and be a sufficient cause
for annulling the marriage at the discretion of the court. But by far
the chief importance under this head is assigned by the Commission to
education and instruction. We see here the vindication of those who for
years have been teaching that the first essential in dealing with
venereal disease is popular enlightenment. There must be more careful
instruction--"through all types and grades of education"--on the sexual
relations in regard to conduct, while further instruction should be
provided in evening continuation schools, as well as factories and
works, with the aid of properly constituted voluntary associations.
These are sound and practical recommendations which, as the Government
has realised, can be put in action at once. A few years ago any attempt
to control venereal disease was considered by many to be almost impious.
Such disease was held to be the just visitation of God upon sin and to
interfere would be wicked. We know better now. A large proportion of
those who are most severely struck by venereal disease are new-born
children and trustful wives, while a simple kiss or the use of towels and
cups in common has constantly served to spread venereal disease in a
family. Even when we turn to the commonest method of infection, we have
still to remember that we are dealing largely with inexperienced youths,
with loving and trustful girls, who have yielded to the deepest and most
volcanic impulse of their natures, and have not yet learnt that that
impulse is a thing to be held sacred for their own sakes and the sake of
the race. In so far as there is sin, it is sin which must be shared by
those who have failed to train and enlighten the young. A Pharisaic
attitude is not only highly mischievous in its results, but is here
altogether out of place. Much harm has been done in the past by the
action of Benefit Societies in withholding recognition and treatment from
venereal disease.
It is evident that this thought was at the back of the minds of those
who framed these wise recommendations. We cannot expect to do away all
at once with the feeling that venereal disease is "shameful." It may
not even be desirable. But we can at least make clear that, in so far
as there is any shame, it must be a question between the individual and
his own conscience. From the point of view of science, syphilis and
gonorrhoea are just diseases, like cancer and consumption, the only
diseases with which they can be compared in the magnitude and extent of
their results, and therefore it is best to speak of them by their
scientific names, instead of trying to invent vague and awkward
circumlocutions. From the point of view of society, any attitude of
shame is unfortunate, because it is absolutely essential that these
diseases should be met in the open and grappled with methodically and
thoroughly. Otherwise, as the Commission recognises, the sufferer is
apt to become the prey of ignorant quacks whose inefficient treatment
is largely responsible for the development of the latest and worst
afflictions these diseases produce when not effectually nipped in the
bud. That they can be thus cut short--far more easily than consumption,
to say nothing of cancer--is the fact which makes it possible to hope
for a conquest over venereal disease. It is a conquest that would make
the whole world more beautiful and deliver love from its ugliest
shadow. But the victory cannot be won by science alone, not even in
alliance with officialdom. It can only be won through the enlightened
co-operation of the whole nation.
[1] The increase of venereal disease during the Great War has been
noted alike in Germany, France, and England. Thus, as regards France,
Gaucher has stated at the Paris Academy of Medicine (_Journal de
Medicine_, May 10th, 1916) that since mobilisation syphilis had
increased by nearly one half, alike among soldiers and civilians; it
had much increased in quite young people and in elderly men. In
Germany, Neisser, a leading authority, states (_Deutsche Medizinische
Wochenschrift_, 14th Jan., 1915) that the prevalence of venereal
disease is much greater than in the war of 1870, and that "every day
many thousands, not to say tens of thousands, of otherwise able-bodied
men are withdrawn from the service on this account."
[2] The chief is Iwan Bloch who, in his elaborate work, _Der Ursprung
der Syphilis_ (2 vols., 1901, 1911), has fully investigated the evidence.
[3] N. Bishop Harman, "The Influence of Syphilis on the Chances of
Progeny," _British Medical Journal_, Feb. 5th, 1916.
[4] It is true that in my book, _Sex in Relation to Society_ (Ch. VIII.)
I have stated my belief that notification, as in the case of other
serious infectious diseases, is the first step in the conquest of
venereal disease. I still think it ought to be so. But a yet more
preliminary step is popular enlightenment as to the need for such
notification. The recommendations seem to me to go as far as it is
possible to go at the moment in English-speaking countries without
producing friction and opposition. In so far as they are carried out
the recommendations will ensure the necessary popular enlightenment.
XII
THE NATIONALISATION OF HEALTH
It was inevitable that we should some day have to face the problem of
medical reorganisation on a social basis. Along many lines social
progress has led to the initiation of movements for the improvement
of public health. But they are still incomplete and imperfectly
co-ordinated. We have never realised that the great questions of health
cannot safely be left to municipal tinkering and the patronage of
Bumbledom. The result is chaos and a terrible waste, not only of what
we call "hard cash," but also of sensitive flesh and blood. Health,
there cannot be the slightest doubt, is a vastly more fundamental and
important matter than education, to say nothing of such minor matters
as the post office or the telephone system. Yet we have nationalised
these before even giving a thought to the Nationalisation of Health.
At the present day medicine is mainly in the hands, as it was two
thousand years ago, of the "private practitioner." His mental status
has, indeed, changed. To-day he is submitted to a long and arduous
training in magnificently equipped institutions; all the laboriously
acquired processes and results of modern medicine and hygiene are
brought within the student's reach. And when he leaves the hospital,
often with the largest and noblest conception of the physician's place
in life, what do we do with him? He becomes a "private practitioner,"
which means, as Duclaux, the late distinguished Director of the Pasteur
Institute, put it, that we place him on the level of a retail grocer
who must patiently stand behind his counter (without the privilege of
advertising himself) until the public are pleased to come and buy
advice or drugs which are usually applied for too late to be of much
use, and may be thrown away at the buyer's good pleasure, without the
possibility of any protest by the seller. It is little wonder that in
many cases the doctor's work and aims suffer under such conditions; his
nature is subdued to what it works in; he clings convulsively to his
counter and its retail methods.
The fact is--and it is a fact that is slowly becoming apparent to
all--that the private practice of medicine is out of date. It fails to
answer the needs of our time. There are various reasons why this should
be the case, but two are fundamental. In the first place, medicine has
outgrown the capacity of any individual doctor; the only adequate
private practitioner must have a sound general knowledge of medicine
with an expert knowledge of a dozen specialties; that is to say, he must
give place to a staff of doctors acting co-ordinately, for the present
system, or lack of system, by which a patient wanders at random from
private practitioner to specialist, from specialist to specialist
_ad infinitum_, is altogether mischievous. Moreover, not only is it
impossible for the private practitioner to possess the knowledge
required to treat his patients adequately: he cannot possess the
scientific mechanical equipment nowadays required alike for diagnosis
and treatment, and every day becoming more elaborate, more expensive,
more difficult to manipulate. It is installed in our great hospitals
for the benefit of the poorest patient; it could, perhaps, be set up
in a millionaire's palace, but it is hopelessly beyond the private
practitioner, though without it his work must remain unsatisfactory and
inadequate.[1] In the second place, the whole direction of modern
medicine is being changed and to an end away from private practice; our
thoughts are not now mainly bent on the cure of disease but on its
prevention. Medicine is becoming more and more transformed into hygiene,
and in this transformation, though the tasks presented are larger and
more systematic, they are also easier and more economical. These two
fundamental tendencies of modern medicine--greater complexity of its
methods and the predominantly preventive character of its aims--alone
suffice to render the position of the private practitioner untenable. He
cannot cope with the complexity of modern medicine; he has no authority
to enforce its hygiene.
The medical system of the future must be a national system co-ordinating
all the conditions of health. At the centre we should expect to find a
Minister of Health, and every doctor of the State would give his whole
time to his work and be paid by salary which in the case of the higher
posts would be equal to that now fixed for the higher legal offices, for
the chief doctor in the State ought to be at least as important an
official as the Lord Chancellor. Hospitals and infirmaries would be alike
nationalised, and, in place of the present antagonism between hospitals
and the bulk of the medical profession, every doctor would be in touch
with a hospital, thus having behind him a fully equipped and staffed
institution for all purposes of diagnosis, consultation, treatment, and
research, also serving for a centre of notification, registration,
preventive and hygienic measures. In every district the citizen would
have a certain amount of choice as regards the medical man to whom he
may go for advice, but no one would be allowed to escape the medical
supervision and registration of his district, for it is essential that
the central Health Authority of every district should know the health
conditions of all the inhabitants of the district. Only by some such
organised and co-ordinated system as this can the primary conditions of
Health, and preventive measures against disease, be genuinely socialised.
These views were put forward by the present writer twenty years ago in
a little book on _The Nationalisation of Health_, which, though it met
with wide approval, was probably regarded by most people as Utopian.
Since then the times have moved, a new generation has sprung up, and
ideas which, twenty years ago, were brooded over by isolated thinkers
are now seen to be in the direct line of progress; they have become the
property of parties and matters of active propaganda. Even before the
introduction of State Insurance Professor Benjamin Moore, in his able
book, _The Dawn of the Health Age_, anticipating the actual march of
events, formulated a State Insurance Scheme which would lead on, as he
pointed out, to a genuinely National Medical Service, and later, Dr.
Macilwaine, in a little book entitled _Medical Revolution_, again
advocated the same changes: the establishment of a Ministry of Health,
a medical service on a preventive basis, and the reform of the
hospitals which must constitute the nucleus of such a service. It may
be said that for medical men no longer engaged in private practice it
is easy to view the disappearance of private practice with serenity;
but it must be added that it is precisely that disinterested serenity
which makes possible also a clear insight into the problems and a wider
view of the new horizons of medicine. Thus it is that to-day the
dreamers of yesterday are justified.
The great scheme of State Insurance was certainly an important step
towards the socialisation of medicine. It came short, indeed, of the
complete Nationalisation of Health as an affair of State. But that
could not possibly be introduced at one move. Apart even from the
difficulty of complete reorganisation, the two great vested interests
of private medical practice on the one hand and Friendly Societies on
the other would stand in the way. A complicated transitional period is
necessary, during which those two interests are conciliated and
gradually absorbed. It is this transitional period which State
Insurance has inaugurated. To compare small things to great--as we may,
for the same laws run all through Nature and Society--this scheme
corresponds to the ancient Ptolomaean system of astronomy, with its
painfully elaborate epicycles, which preceded and led on to the sublime
simplicity of the Copernican system. We need not anticipate that the
transitional stage of national insurance will endure as long as the
ancient astronomy. Professor Moore estimated that it would lead to a
completely national medical service in twenty-five years, and since the
introduction of that method he has, too optimistically, reduced the
period to ten years. We cannot reach simplicity at a bound; we must
first attempt to systematise the recognised and established activities
and adjust them harmoniously.
The organised refusal of the medical profession at the outset to carry
on, under the conditions offered, the part assigned to it in the great
National Insurance scheme opened out prospects not clearly realised by
the organisers. No doubt its immediate aspects were unfortunate. It not
only threatened to impede the working of a very complex machine, but it
dismayed many who were not prepared to see doctors apparently taking up
the position of the syndicalists, and arguing that a profession which
is essential to the national welfare need not be carried out on
national lines, but can be run exclusively by itself in its own
interests. Such an attitude, however, usefully served to make clear how
necessary it is becoming that the extension of medicine and hygiene in
the national life should be accompanied by a corresponding extension in
the national government. If we had had a Council of National Health, as
well as of National Defence, or a Board of Health as well as a Board of
Trade, a Minister of Health with a seat in the Cabinet, any scheme of
Insurance would have been framed from the outset in close consultation
with the profession which would have the duty of carrying it out. No
subsequent friction would have been possible.
Had the Insurance scheme been so framed, it is perhaps doubtful whether
it would have been so largely based on the old contract system. Club
medical practice has long been in discredit, alike from the point of
view of patient and doctor. It furnishes the least satisfactory form of
medical relief for the patient, less adequate than that he could obtain
either as a private patient or as a hospital patient. The doctor, on
his side, though he may find it a very welcome addition to his income,
regards Club practice as semi-charitable, and, moreover, a form of
charity in which he is often imposed on; he seldom views his club
patients with much satisfaction, and unless he is a self-sacrificing
enthusiast, it is not to them that his best attention, his best time,
his most expensive drugs, are devoted. To perpetuate and enlarge the
club system of practice and to glorify it by affixing to it a national
seal of approval, was, therefore, a somewhat risky experiment, not
wisely to be attempted without careful consultation with those most
concerned.
Another point might then also have become clear: the whole tendency of
medicine is towards a recognition of the predominance of Hygiene. The
modern aim is to prevent disease. The whole national system of medicine
is being slowly though steadily built up in recognition of the great
fact that the interests of Health come before the interests of Disease.
It has been an unfortunate flaw in the magnificent scheme of Insurance
that this vital fact was not allowed for, that the old-fashioned notion
that treatment rather than prevention is the object of medicine was
still perpetuated, and that nothing was done to co-ordinate the
Insurance scheme with the existing Health Services.
It seems probable that in a Service of State medical officers the
solution may ultimately be found. Such a solution would, indeed,
immensely increase the value of the Insurance scheme, and, in the end,
confer far greater benefits than at present on the millions of people who
would come under its operation. For there can be no doubt the Club system
is not only unscientific; it is also undemocratic. It perpetuates what
was originally a semi-charitable and second-rate method of treatment of
the poorer classes. A State medical officer, devoting his whole time and
attention to his State patients, has no occasion to make invidious
distinctions between public and private patients.
A further advantage of a State Medical Service is that it will facilitate
the inevitable task of nationalising the hospitals, whether charitable or
Poor-law. The Insurance Act, as it stands, opens no definite path in this
direction. But nowadays, so vast and complicated has medicine become,
even the most skilful doctor cannot adequately treat his patient unless
he has a great hospital at his back, with a vast army of specialists and
research-workers, and a manifold instrumental instalment.
A third, and even more fundamental, advantage of a State Medical Service
is that it would help to bring Treatment into touch with Prevention. The
private practitioner, as such, inside or outside the Insurance scheme,
cannot conveniently go behind his patient's illness. But the State doctor
would be entitled to ask: _Why_ has this man broken down? The State's
guardianship of the health of its citizens now begins at birth (is
tending to be carried back before birth) and covers the school life. If
a man falls ill, it is, nowadays, legitimate to inquire where the
responsibility lies. It is all very well to patch up the diseased man
with drugs or what not. But at best that is a makeshift method. The
Consumptive Sanatoriums have aroused enthusiasm, and they also are all
very well. But the Charity Organisation Society has shown that only about
50 per cent. of those who pass through such institutions become fit for
work. It is not more treatment of disease that we want, it is less need
for treatment. And a State Medical Service is the only method by which
Medicine can be brought into close touch with Hygiene.
The present attitude of the medical profession sometimes strikes people
as narrow, unpatriotic, and merely self-interested. But the Insurance
Act has brought a powerful ferment of intellectual activity into the
medical profession which in the end will work to finer issues. A
significant sign of the times is the establishment of the State Medical
Service Association, having for its aim the organisation of the medical
profession as a State Service, the nationalisation of hospitals, and
the unification of preventive and curative medicine. To many in the
medical profession such schemes still seem "Utopian"; they are blind to
a process which has been in ever increasing action for more than half a
century and which they are themselves taking part in every day.
[1] The result sometimes is that the ambitious doctor seeks to become
a specialist in at least one subject, and instals a single expensive
method of treatment to which he enthusiastically subjects all his
patients. This would be comic if it were not sometimes rather tragic.
XIII
EUGENICS AND GENIUS
The cry is often heard to-day from those who watch with disapproval the
efforts made to discourage the reckless procreation of the degenerate
and the unfit: You are stamping out the germs of genius! It is widely
held that genius is a kind of flower, unknown to the horticulturist,
which only springs from diseased roots; make the plant healthily sound
and your hope of blossoms is gone, you will see nothing but leaves. Or,
according to the happier metaphor of Lombroso, the work of genius is an
exquisite pearl, and pearls are the product of an obscure disease. To
the medical mind, especially, it has sometimes been, naturally and
properly no doubt, a source of satisfaction to imagine that the
loveliest creations of human intellect may perhaps be employed to shed
radiance on the shelves of the pathological museum. Thus we find eminent
physicians warning us against any effort to decrease the vigour of
pathological processes, and influential medical journals making solemn
statements in the same sense. "Already," I read in a recent able and
interesting editorial article in the _British Medical Journal_,
"eugenists in their kind enthusiasm are threatening to stamp out the
germs of possible genius."